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Which had a coronary occlusion, and how acute were they? Jesse McLaren explains 'Late STEMI' and how reperfusion strategies should not be based on time of symptom onset. The post ECG Cases 25: ‘Late STEMI’ – How acute is the coronary occlusion? appeared first on Emergency Medicine Cases.
To support EM Cases, please consider a donation here: [link] The post EM Quick Hits 57 – HIV Diagnosis, Failed Paradigm of STEMI Criteria, Poisoned Patient Airway Management, Spontaneous Bacterial Peritonitis, DIY Investments appeared first on Emergency Medicine Cases.
Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. We looked at 101 STEMI patients from two rural EDs. Date: November 22, 2023 Reference: Stopyra et al. AEM November 2023.
10 patients presented with the "STEMI-equivalent" ST elevation in aVR with diffuse ST depression. Which had acute coronary occlusion? The post ECG cases 7: ST elevation in aVR, STEMI-equivalent? Jesse McLaren guides us through the differential diagnosis of ST elevation in aVR with diffuse ST depression in this ECG Cases blog.
Which had acute coronary occlusion? The post ECG Cases 4: Lateral STEMI or Occlusion MI? In this ECG Cases blog we look at seven patients with potentially ischemic symptoms and subtle ECG changes in the lateral leads. Introducing the concept of Occlusion MI - a paradigm shift in ECG diagnosis of MI.
If it looks and feels like a STEMI clinically, get serial ECGs and consult Cardiology immediately. Post Created By: William Caputo MD Post Peer Reviewed By: Anand Swaminathan MD, MPH (Twitter @EMSwami ) The post REBEL Core Cast 104.0 – Subtle ECGs in Acute Coronary Occlusion appeared first on REBEL EM - Emergency Medicine Blog.
EKG Show Details EKG Characteristics Rate 54 Rhythm Sinus Bradycardia Intervals Normal PR, QRS, QT Intervals Axis Normal ST Segments ST Depression in Leads V2-V6 Diagnosis Diagnosis: Posterior STEMI Questions What is the next test that should be obtained in the management of this patient? Sources Burns, E., Cadogan, M., & Cadogan, E.
Jesse McLaren on when to consider Spontaneous Coronary Artery Dissection (SCAD), which patients are at risk for reocclusion, and the challenges of diagnosing SCAD in patients who have nonischemic ECGs despite silent occlusion, occlusions perfused by collaterals, or from non-occlusive MI on this ECG Cases.
Background: Primary PCI is the recommended reperfusion strategy in patients with STEMI and should be initiated within 2 hours after first medical contact. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial.
Traditionally, emergency providers looked for signs of ST-segment elevation myocardial infarction (STEMI) to indicate the need for intervention. Emergency physicians have recognized for some time that there are many occlusions of the coronary arteries that do not present with classic STEMI criteria on the ECG.
Here is his ED ECG at triage: Obvious high lateral OMI that does not quite meet STEMI criteria. Compensatory enlargement was defined as being present when the total coronary arterial cross-sectional area at the stenotic site was greater than that at the proximal nonstenotic site. He was started on nitro gtt.
EKG Show Details EKG Characteristics Rate 54 Rhythm Sinus Bradycardia Intervals Normal PR, QRS, QT Intervals Axis Normal ST Segments ST Depression in Leads V2-V6 Diagnosis Diagnosis: Posterior STEMI Questions What is the next test that should be obtained in the management of this patient? Sources Burns, E., Cadogan, M., & Cadogan, E.
I sent this to the Queen of Hearts So the ECG is both STEMI negative and has no subtle diagnostic signs of occlusion. Similarly, if a patient with known CAD presents with refractory ischemic chest pain, the ECG barely matters: the pre-test likelihood of acute coronary occlusion is so high that they need an emergent angiogram.
The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. There’s only minimal ST elevation in III, which does not meet STEMI criteria of 1mm in two contiguous leads. But STEMI criteria is only 43% sensitive for OMI.[1]
The Case A 62-year-old male with a history of Hypertension, Hyperlipidemia, Coronary Artery Disease with stents, Pulmonary Embolism on Eliquis, presents with sudden onset, severe, mid-sternal chest pain that started 15 minutes prior to arrival. Serial ECG's should be obtained to assess for evolution to acute STEMI.
LVH produces secondary repolarization abnormalities that can mimic STEMI. Which had an acute coronary occlusion? Signs of occlusion MI in patients with LVH include: new Q waves/loss of R waves, disproportionate and dynamic ST elevation (or ST depression from posterior MI), and hyperacute T waves.
So while there’s no diagnostic STEMI criteria, there are multiple ischemic abnormalities in 11/12 leads involving QRS, ST and T waves, which are diagnostic of a proximal LAD occlusion. First trop was 7,000ng/L (normal 25% of ‘Non-STEMI’ patients with delayed angiography have the exact same pathology of acute coronary occlusion.
Obvious infero-postero-lateral STEMI(+)OMI, regardless of context Now let’s put them in order: what was the sequence? When the pain recurred the ECG normalized(ECG#2), but this is pseudonormalization : the coronary artery has spontaneously reoccluded, and the T waves are on their way up. What was the outcome and final diagnosis?
But do they represent acute coronary occlusion? But coronaries were normal, and serial high sensitivity troponin was undetectable. Based on ECG changes and echo findings, the patient was diagnosed as coronary vasospasm. Formal echo showed EF 55% with mild inferolateral hypokinesis without any prior for comparison.
Cath lab declined as it is not a STEMI." And now this finding is even formally endorsed as a "STEMI equivalent" in the 2022 ACC guidelines!!! Another myocardial wall is sacrificed at the altar of the STEMI/NonSTEMI mindset. Do NOT give it unless you are committed to the cath lab!! Cath attending is aware. It is a mass delusion.
A second 12 Lead ECG was recorded: This is a testament to the dynamic nature of coronary thrombosis and thrombolysis. Here the ST segments are not so deep, nor are the T waves so wide and bulky, because of improved coronary flow at the level of the occlusion. it has been subsequently deemed a STEMI-equivalent.
Additional architectural changes include systolic anterior motion of the mitral valve, endothelial dysfunction at the level of the coronary arterial bed, and ventricular diastolic dysfunction. This worried the crew of potential acute coronary syndrome and STEMI was activated pre-hospital. It is spread to V2 and V3.
He denied any known medical history, specifically: coronary artery disease, hypertension, dyslipidemia, diabetes, heart failure, myocardial infarction, or any prior PCI/stent. It doesn’t meet any conventional STEMI criteria, but there is patently obvious increased area under the curve. Breath sounds were clear in all lung fields.
The scan also showed “scattered coronary artery plaques”. __ Smith comment 1 : the appropriate management at this point is to lower the blood pressure (lower afterload, which increases myocardial oxygen demand). They too have dense white masses consistent with coronary atherosclerosis. The blue circle shows the LCx.
Old ‘NSTEMI’ A history of coronary artery disease and a stent to the same territory further increases pre-test likelihood of acute coronary occlusion, including in-stent thrombosis. So this NSTEMI was likely a STEMI(-)OMI with delayed reperfusion. Fortunately the patient did not reocclude while awaiting the angiogram.
But cardiac arrest is a period of near zero flow in the coronary arteries and causes SEVERE ischemia. Cardiac arrest #3: ST depression, Is it STEMI? Smith's ECG Blog ( See My Comment in the March 1, 2023 post) — DSI does not indicate acute coronary occlusion! It also does not uniformly indicate severe coronary disease.
Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. years old ± 13.7
Acute coronary syndrome (ACS) is responsible for the majority (60%) of all OHCAs in patients. There is evidence that taking those patients with ROSC and EKG showing STEMI directly for angiography +/- angioplasty is associated with positive patient-oriented outcomes.
Many conditions outside of acute coronary syndrome (ACS) mimic ST-elevation myocardial infarction (STEMI), but only a handful of cases have reported ST-elevations (STE) in the setting of pancreatic inflammation where underlying ACS was excluded. Mimics of ST elevation myocardial infarction (STEMI). Accessed November 29, 2023.
The ECG shows an inferior ST-Elevated Myocardial Infarction (STEMI). Studies have shown that oxygen can cause vasoconstriction, increase blood pressure and decrease coronary artery blood flow ( Kones et al AM J Med 2011). They give him 180mg of ASA to chew and package him for transportation to the hospital. Class IIb, LOE C-LD)
While STEMI negative, the ECG is diagnostic of proximal LAD occlusion. Transient STEMI” are often managed like non-STEMI with delayed angiography, which is very risky. This case is an example of the steps we can all take in daily practice as the paradigm shifts from STEMI to OMI.
I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: You can subscribe for news and early access (via participating in our studies) to the Queen of Hearts here: [link] queen-form Then I learned that a Code STEMI was activated for concern of anterior "STEMI" in V1-V2. High sensitivity troponin I was 23 ng/L.
I came to work one day and one of my partners said, "Hey, Steve, we had a STEMI this afternoon!" That is not a STEMI. They had activated the cath lab and the interventionalist did not notice that it was not a STEMI/OMI. I said, "Cool, can I see the ECG?' Of course he said: "Yes, it was a 60 year old diabetic with Chest pain."
Patient still not having chest pain however this is more concerning for OMI/STEMI. Wellens' syndrome is a syndrome of Transient OMI (old terminology would be transient STEMI). A comparison of electrocardiographic changes during reperfusion of acute myocardial infarction by thrombolysis or percutaneous transluminal coronary angioplasty.
A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Additionally, his cardiac telemetry monitor showed runs of accelerated idioventricular rhythm, a benign arrhythmia often associated with coronary reperfusion.
Their OMI Manifesto details how use of standard STEMI criteria results in an unacceptable level of inaccuracy, in which an estimated 25-30% of acute coronary occlusions are missed! The article by Aslanger, Smith et al that is featured above in today’s post has just been published.
According to this data a triage ECG labeled ‘normal’ rules out the possibility of acute coronary occlusion. We also studied 7 years of Code STEMI patients requiring emergent reperfusion, and found that 4% presented with an ECG labeled ‘normal’, often confirmed by the final blinded interpretation.
Smith , d and Muzaffer Değertekin a DIFOCCULT: DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction. Coronary arteries cannot be assessed because the scan was not gated, but proximal segments of the coronary arteries seem to be open with some contrast. Again nothing diagnostic.
Below is the version standardized by PM Cardio app Meyers interpretation: Findings are specific for posterior (and also likely inferior) wall transmural acute infarction, most likely due to acute coronary occlusion (OMI). Smith Comment: Is is common for the artery to be open at angiogram in OMI, including full STEMI.
A prehospital STEMI activation was transmitted to the closest PCI center, and 324mg ASA was administered. One cannot rely on this feature as a means of detecting changes – subtle, or dramatic – for volatile occlusive coronary thrombus. It’s important to stress the presence of a normal QRS (i.e., The pathology is now painfully evident.
The conventional machine algorithm interpreted this ECG as STEMI. See this post of RV MI with both McConnell sign and "D" sign: Inferior and Posterior STEMI. Thanks in part to rapid bedside diagnosis, the patient was able to avoid emergent coronary angiography. When EMS found her, she was dyspneic and diaphoretic.
At the hospital a 12-lead ECG is recorded within 10 minutes and read by the attending physician, who activates the “Code STEMI” protocol. Is this a STEMI? So technically it is a STEMI equivalent. The STEMI guidelines require 2 mm of ST-segment elevation in leads V2 and V3 for men (1.5 The answer is yes!
4,5] We have now formally studied this question: Emergency department Code STEMI patients with initial electrocardiogram labeled ‘normal’ by computer interpretation: a 7-year retrospective review.[6] have published a number of warnings about the previous reassuring studies.[4,5]
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